The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

Impaired perineal skin integrity

Protein-calorie malnutrition

Pain related to abdominal cramping

Fluid and electrolyte imbalance

Answer and Explanation

The Correct Answer is D

A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.

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Correct Answer is ["A","C","D"]

Explanation

A. Excessive thirst (polydipsia) is a common symptom of hyperglycemia due to dehydration caused by increased urination.
B. Anxiety and tremors are more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia.
C. Excessive urination (polyuria) is a hallmark of hyperglycemia as the body attempts to excrete excess glucose through urine.
D. "Acetone" or "fruity" breath odor is a characteristic sign of diabetic ketoacidosis (DKA), which can occur in severe hyperglycemia.
E. Slow, shallow respirations are not typically associated with hyperglycemia but may occur in cases of respiratory acidosis or DKA, where Kussmaul's breathing (deep, rapid breathing) is more common.

Correct Answer is ["300"]

Explanation

· Calculate the time elapsed: From 0330 to 0600 is 2.5 hours.

· Calculate the total volume infused: 2.5 hours X 120 mL/hour = 300 mL

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The nurse is caring for a client who was admitted for an acute exacerbation of Crohn's Disease with severe diarrhea for the last two days. The nurse knows that which of the following is the priority risk for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes which of the following as signs and symptoms of hyperglycemia? (Select All that Apply)

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

Correct Answer is ["300"]

Explanation

Which of the following is a potential complication for a client whose potassium level is 6.5 mEq/L?

An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate?

A nurse is preparing to administer an infusion of intravenous fluids to a client who is at risk for fluid volume overload. Which of the following manifestations would indicate hypervolemia? (Select all that apply)

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Which classification of urinary tract infection (UTI) is described as infection of the kidneys and ureters?

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?